405850002-4-14-2022-29-AS-KBUY-CDLNJK-20220418103029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850002
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:43:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20200909085757

FACILITY NAME:	YELLOW ROSE ASSISTED LIVING		FACILITY NUMBER:	405850002
ADMINISTRATOR:	TESFAZGY, ABIY		FACILITY TYPE:	740
ADDRESS:	4225 CAMP 8 RD		TELEPHONE:	(805) 286-8477
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	15	CENSUS:	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Abiy Tesfazgy, Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Residents are not being adequately fed.
Facility lacks adequate supplies.
Facility is odoriferous.
Facility lacks a food menu.
Facility is in disrepair.
Residents are not being given the right medications.
Facility lacks a fire extinguisher.
Facility does not provide a safe environment for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint investigation to the facility above to issue final findings. LPA met with Abiy Tesfazgy, Administrator, and explained the purpose of the visit. LPA Jeffries started the investigation on 9/10/2020 and met with the administrator telephonically, and conducted resident interviews on 10/5/2020. LPA Olson conducted additional staff interviews on 4/14/22, and had additional observations on 3/18/22.

On the allegation: Residents are not being adequately fed. To investigate this allegation, the LPA interviewed staff and residents, obtained photographic evidence, and observed the facility during a Facetime video walkthrough. Based on the evidence gathered, it was determined that the facility produces and prepares breakfast, lunch and dinner for all residents of the facility seven days a week and provides snacks. It was observed, photographed and confirmed by interviews that the supply of food was of the quality and variety to meet the dietary needs of the residents daily. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20200909085757

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YELLOW ROSE ASSISTED LIVING	FACILITY NUMBER: 405850002
	VISIT DATE: 04/14/2022

NARRATIVE

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On the allegation: Facility lacks adequate supplies. Based on interviews conducted and observation from the Facetime video walk through, it was determined that the facility had adequate supplies for the residents. Observations and interviews revealed no issues regarding supplies in hygiene, bedding, cleaning items or toiletries at any time. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Facility is odoriferous. LPA Olson conducted a tour of the facility on 4/14/22. LPA did not observe any odors in the facility. Interviews with residents and staff also revealed no issues with odors. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Facility lacks a food menu. On 9/10/2020, the administrator provided a copy of the facility’s sample menu. The facility is not required to keep or provide an accurate weekly menu due to its capacity, and is only required to have a sample menu on file. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Facility is in disrepair. It was alleged that the facility’s garbage disposal was broken for 18 months. On the 9/10/2020 visit conducted by LPA Jeffries, the LPA observed the garbage disposal was not working and the administrator acknowledged it. Administrator stated it was repaired in November 2020 and took over a month for the part to arrive due to COVID-19. The garbage disposal did not effect resident care. Resident and staff interviews revealed the facility was in good working order and they had no concerns. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Residents are not being given the right medications. The complainants concern was that doctors and nurses were not prescribing the right medications which is not a Title 22 regulation. LPA reviewed medication records for August and September 2020. The Medication Administration Record (MAR) indicated all medications were given as prescribed. On 4/14/22, Administrator explained the facility’s medication process that includes 2 staff verifying the medications before they are provided to the residents. One staff prepares the medications for each med pass and a second staff verifies the medications. LPA reviewed a sample of medications and noted all medications reviewed were given as prescribed. Based on the information obtained, the allegation is deemed unsubstantiated at this time.
Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20200909085757

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YELLOW ROSE ASSISTED LIVING	FACILITY NUMBER: 405850002
	VISIT DATE: 04/14/2022

NARRATIVE

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On the allegation: Facility lacks a fire extinguisher. On the 9/10/2020 Facetime walk through, LPA Jeffries noted multiple fire extinguishers in the facility. On 4/14/22, LPA Olson observed 4 fire extinguishers, one in the kitchen, one in the office, one in the North wing and one in the South wing. All 4 were were fully charged. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Facility does not provide a safe environment for residents. It was alleged that the front yard of the facility had “a lot of needle weeds” which posed a potential danger of scratching residents. LPA observed the facility has a large, fully paved driveway and walkway in the front yard. On 3/18/22 and 4/14/22, LPA Olson observed no overgrown or dangerous plants in the front or back yard. On 10/5/2020 and 4/14/22, residents interviewed stated they felt safe and comfortable at the facility. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

Exit interview, report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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